B. Describe a diagnostic approach/method to the patient with this problem.

When the chief complaint is chest pain the first differentiation that has to be made it between emergent and non-emergent causes of chest pain. The evaluation for emergent causes of chest pain includes: focused history and physical, 12-lead electrocardiogram (EKG) and chest radiograph (CXR). Once this quick evaluation for emergent causes of chest pain has been completed, a more detailed history and physical should be obtained along with pertinent lab data and diagnostic testing.

1. Historical information important in the diagnosis of this problem.

Description of the Pain

Location

Ischemic pain can be substernal. Pulmonary causes of chest pain can localize to the chest wall. Esophageal causes of chest pain are often in the epigastric area. Chest wall causes of chest pain are often localized to a specific area.

Radiation

Ischemic pain can radiate to the jaw and left arm. Aortic dissection pain can radiate to the back, intrascapular region or abdomen. Cervical disc disease pain can radiate into the arms.

Quality

Certain causes of chest pain have a different quality. Ischemic chest pain is characterized by pressure, tightness and squeezing. Aortic dissection is characterized by a tearing or ripping pain going to the back. Pulmonary embolism is associated with pleuritic chest pain. Pneumothorax is associated with sudden sharp and pleuritic pain. Esophageal reflux pain can be associated with a burning sensation. Biliary and pancreatic causes of chest pain often have abdominal pain associated with them.

Severity

While this is very variable, pain associated with aortic dissection, esophageal rupture, perforating ulcer, and tension pneumothorax is severe.

Onset

Aortic dissection, esophageal perforation and tension pneumothorax have a sudden onset of pain. Ischemic pain can be associated with increased activity. Rib fractures can be associated with trauma.

Exacerbating and Relieving Factor

Ischemic pain may be relieved by rest. Pericardial pain may be improved by sitting up and leaning forward or made worse with inspiration and lying down. Rib fracture pain can be positional. Cervical disc disease pain can be worsened with neck movement, coughing or sneezing. Of note, response to antacids and nitroglycerin is not reliable.

Associated Symptoms

Shortness of breath? Ischemic heart disease, pulmonary causes of chest pain, esophageal rupture, and anxiety can be associated with shortness of breath.

Have you recently had any?

Major surgery or medical procedure? Major procedures are a risk for pulmonary embolism; however, specific procedures increase risk for specific kinds of chest pain (endoscopy can be associated with esophageal problems).

Periods of immobilization? Prolonged immobilization is a risk for pulmonary embolism.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem

Physical exam can often be relatively normal in a patient with chest pain. Specific maneuvers (in alphabetical order) that can aid you are:

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

Diagnosis: Ischemic heart disease

History - pain: a) can be characterized by pressure, tightness and squeezing, b) can be associated with increased activity and relieved by rest, c) can be associated with shortness of breath and nausea. Risk factors include diabetes, hypertension, hypercholesterolemia, tobacco abuse, and family history of ischemic heart disease.

EKG - presence of ST segment elevation, presence of ST segment depression, presence of T wave inversions. If standard EKG is inconclusive and patient continues to have ischemic symptoms, additional leads should be recorded to detect right ventricular infraction or left circumflex occlusion (detected on V3R and V4R and V7- V9).

Cardiac CT - anatomic coronary artery delineation: useful for low- to intermediate-probability chest pain patients presenting to emergency department without signs of ischemia on EKG and or inconclusive cardiac troponin to exclude CAD. It is not useful in patients with known CAD.

Cardiac MRI - anatomic and function imaging: Can differentiate scar from recent infraction as well as other cardiomyopathy, such as myocarditis and Takotsubo cardiomyopathy.

Diagnosis: Aortic dissection

History - pain is characterized by tearing and ripping, radiating to the back with sudden onset and severe in nature. Can present with syncope. Risk factors include hypertension, arteriosclerosis, advanced age, Marfan syndrome, connective tissue disease, and Turner's syndrome.

Labs - obtain troponin and complete blood count (CBC) to rule out other causes. Also, elevated D-dimer can be used to rule out acute aortic dissection in patients with low likelihood of the disease.

Radiology - CXR can show the following: widened mediastinum, loss of aortic contour, displacement of aorta, and pleural effusion.

Cardiac testing - transesophageal echo, CT of the chest or MRI of the chest can all diagnose and further characterize dissection.

Important point - the triad of immediate and maximal tearing or ripping pain, pulse or blood pressure differential, and mediastinal widening can identify up to 96% of patients with aortic dissection.

Diagnosis: Pericarditis

History - pain is a sharp pain that can radiate to the back, neck or shoulders and can worsen with inspiration and lying down while improved with sitting up and leaning forward. Dyspnea can be associated with this as well. An upper respiratory infection may precede this.

Transthoracic echocardiography - can show pericardial effusion. Features which suggest cardiac tamponade includes collapse of any cardia chamber, earliest sign is diastolic collapse of right atrium.

Note: Myopericarditis is diagnosed when there is evidence of pericarditis along with either increased levels of cardiac enzymes or new onset of focal or diffuse depressed left ventricular function on imaging in absence of any other cause.

Diagnosis: Pneumonia

History - can include fever, cough / phlegm, URI symptoms, and pleuritic chest pain. The elderly can present with alteration in mental status.

Ventilation/perfusion (V/Q) scan - depending on risk stratification can provide diagnosis, frequently results in subsequent imaging because of high number of indeterminant studies.

Cardiac testing.

EKG - most common finding is sinus tachycardia though right heart strain, complete or incomplete RBBB, and S1Q3T3 (prominent S wave in lead I, Q wave in lead III and inverted T wave in lead III) can be seen.

Troponin- can be elevated which suggests increased risk of short-term mortality and serious adverse events.

Radiology - upright CXR usually provides diagnosis, sometimes may be seen on CT chest obtained for other reasons. CT chest can be used to differentiate pulmonary bleb (small areas of subpleural air pockets) from true pneumothorax.

Ultrasound of the abdomen: can differentiate cholecystitis, cholelithiasis, choledocholithiasis. Visualization of radiological Murphy’s signs along with gall bladder wall thickening/edema which is highly suggestive of acute cholecystitis.

Hepatobiliary iminodiacetic acid (HIDA) scan: if diagnosis is unclear during ultrasound of abdomen, HIDA could be obtained. If the gall bladder is not visualized after contrast is administered, highly suggestive of acute cholecystitis.

CT scan of the abdomen: can be used in adjunction with ultrasound of abdomen; more useful when complication of acute cholecystitis or other diagnosis are being considered. CT may fail to detect all gallstones because many stones are isodense with bile.

Magnetic resonance cholangiopancreatography (MRCP): useful when there is concern for stone in common bile duct or cystic duct.

Cardiac testing - can obtain an EKG to rule out other causes.

Diagnosis: Pancreatitis

History - abdominal pain that can radiate to the back, nausea and vomiting.

Esophageal dysphagia is diagnosed with upper endoscopy, trial of proton pump inhibitor therapy/ esophageal pH and impedance testing. If these fail to provide a diagnosis, then manometry is performed to establish a specific esophageal motility disorder.

Diagnosis: Chest wall disease

History - pain is positional or reproducible.

Physical exam - pain is localized and reproducible.

Labs - obtain CBC and troponin to rule out other causes of chest pain.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

While there are no uniformly wasted diagnostic tests the appropriate tests, appropriate testing strategies must be chosen for the patient, or any of the above tests could be considered wasteful.

III. Management while the Diagnostic Process is Proceeding.

A. Management of chest pain.

When the chief complaint is chest pain the first determination should be if the patient is suffering from a potential life-threatening condition. A limited history, physical and quickly obtained EKG and CXR can help determine this.

If the initial work-up suggests a pulmonary embolism administer the following:

IV access.

Supplemental oxygen.

Cardiac monitoring.

Arterial blood gas (ABG) / oximetry.

Pulmonary vascular imaging.

Anticoagulation.

If the initial work-up suggests a pneumothorax administer the following:

IV access.

Supplemental oxygen.

If pneumothorax is < 2-3 cm in size, observation and supplemental oxygen can be used. Serial CXRs are required until there is complete resolution.

If pneumothorax is >3 cm in size or if the patient is symptomatic with chest pain or dyspnea, consider needle aspiration or tube thoracostomy. Clinically unstable patients should have chest tube placement.

Cardiac monitoring.

If the initial work-up suggests an esophageal rupture administer the following:

IV access: Avoidance of oral intake, IV fluid administration.

Admission of ICU.

Supplemental oxygen.

Broad-spectrum antibiotics

Intravenous proton pump inhibitor.

Immediate consultation with Surgery.

If the initial work-up suggests a perforating ulcer administer the following:

IV access: avoidance of oral intake, IV fluid administration.

Admission to ICU.

Supplemental oxygen.

Broad-spectrum antibiotics.

Immediate Surgical consultation.

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

The most important point in managing these patients is not to miss any potentially life-threatening cause of chest pain. Therefore, a focused history and physical, EKG and CXR should be performed quickly, looking for clues for potentially life-threatening causes of chest pain. If any of these causes are identified, then that diagnosis and treatment must be perused.

Areas of caution

Aortic dissection is often missed due to lack of eliciting a proper history and the results are devastating as emergent surgical intervention is required.

Misdiagnosis of chest pain is often the result of misinterpretation of the EKG so care should be taken in reading it and early cardiology consultation should be obtained if there are any questions.

Response to sublingual nitroglycerin or antacids is not a reliable diagnostic maneuver.

"2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, Task Force of the European Society of Cardiology (ESC)". First published online: August 29.
2015.

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